The Affordable Care Act: How It Expands Coverage for Those with Behavioral Health Conditions

2. The Affordable Care Act: How It Expands Coverage for Those with Behavioral Health Conditions Rita Vandivort-Warren, M.S.W. Public Health Analyst, CSAT, SAMHSA Rita.vandivort@samhsa.hhs.gov

3. Behavioral Health Disorders are Common, Costly, Disabling, and Deadly • Cost benefit ratio of 7:1—for every dollar on treatment, save in reduced crime, higher employment and productivity, lower medical bills • Almost 50% of Medicaid beneficiaries will have diagnosable mental health and/or substance use disorder in any given year. • Repeated studies of Medicaid enrollees with SUD demonstrate reduced medical cost after SA treatment & greater than the cost of SA treatment: • ER reduced by 39%, • Hospital stay reduced by 35% and • Total medical costs reduced by 26% 3

4. Savings with Treatment WA State Study on those with SUD, comparing those treated with untreated, showed: • Lower medical costs: –$311 per client per month • Lower state hospital expenses: –$48 per client per month • Lower community psychiatric hospital costs: –$16 per client per month • Higher community outpatient mental health service costs: + $17 per client per month • Lower nursing home care costs: –$56 per client per month • Reduced likelihood of arrest: –16% • Reduced likelihood of convictions for any offense: –15% • Reduced likelihood of felony convictions: –34%

5. New Opportunities in the Affordable Care Act (ACA)

6. 2014 Coverage Expansion Below 133% FPL Up to $14,400 individual or $29,500 family 133 – 400% FPL Up to $43,300 individual or $88,000 family State Exchanges Coverage for essential MH/SA at parity & prevention @ no co-pays Helps individuals and small employers with purchasing health insurance Assist by voucher to pay premiums or cost sharing Develops consumer friendly tools & plain language on insurance One application to both exchanges or Medicaid; can do on the web Medicaid Expansion To Childless Adults • Coverage for essential MH/SA at parity for benchmark plan • Feds pay 100% for 3 years, then down 90% • Simplified enrollment, express apps: web too • Integrated data with State exchanges: one application • Foster kids up to age 26 • Does not affect the coverage of those already included under Medicaid

7. ACA related to Criminal Justice • ACA states that pre-adjudicated individuals who may be incarcerated are still eligible for Medicaid and state exchanges & know have needs: • A 2008 study found between 49% to 87% of those arrested test positive for drugs. 2002 study found 68% of those in jails meet criteria for SUD • About 15% of men and 31% of women in jails have a serious MI and 72% of those have co-occurring SUD • Opportunities: Jurisdictions can leverage ACA coverage expansions to implement or expand jail interventions and clinical practices • Jails can implement Medicaid enrollment strategies • Jails can implement protocols for screening for MH/SUD • With more coverage, can link to treatment for early interventions

8. What Coverage Expansion under ACA Mean for those with Mental and Substance Use Disorders? Impact on Coverage: Many uninsured individuals will be covered in 2014 —most likely by the expansion in Medicaid • Of the 35 Million uninsured that will be covered, 16 million will become newly eligible under Medicaid. • An estimated 1.8 million uninsured have a serious addiction and 3.3 million uninsured have a mental illness • 39% of the individuals served by Mental Health Authorities have no insurance • Nationally, served under programs funded by State Substance Abuse Authorities: • 61% of the individuals served have no insurance; • 87% of these are estimated under 133% FPL

9. Re-Thinking Coverage MA study: although 95% have health insurance, only 84% of those coming to SA facilities have insurance Beyond enrolling: Churning on and off Medicaid from MA experience To engage the Young Invincibles, SA treatment that appeals to the young? Are SA facilities Medicaid ready? 2008 NSSATS: only 58% of SA facilities said accepted Medicaid Medicaid limits payment for non-medical residential SA treatment Enough capacity in SUD treatment for additional 4 million?

10. ACA Promotes Primary Care Integrateswith Specialty Care ACA Focus on primary care and specialty care coordination: Significant enhancements to primary care Incentives for Accountable Care Organizations (ACOs) Dual Medicare and Medicaid Eligibles Bi-directional Integration MH/SUD in primary care Primary care in MH/SUD settings Challenges in collaborating and meeting requirements of 42CFR Part II

11. ACA Section 2703: Medicaid Health Homes Health homes optional coverage: CMS SMD 11/16/10 Includes those with chronic conditions (or at risk) in 6 diseases- includes those with MH and SUD conditions Medicaid state plan amendment- may do multiples, can limit geographically or target by diagnoses 90% match for initial 2 years—big incentives for states; also planning opportunities SAMSHA to consult with states on prevention and treatment of those with MH and SUD conditions Several new services: Comprehensive Care Management Care Coordination and Health Promotion Patient and Family Support Comprehensive Transitional Care Referral to Community and Social Support Services

12. Many Other State Flexibilities Medicaid Home and Community Based services through State Plan Amendments, not waivers (SMD 8-06-10) Medicaid Money Follows the Person more flexible (SMD 6-22-10) Many demos for Dual Eligibles (eligible both Medicare & Medicaid), SMD (7-08-11) offered great financing flexibilities to integrate care Medicaid Emergency Psychiatric Demo for a few states to test Medicaid payments for psychiatric stabilization (SMD 8-09-11) State Rebalancing Initiative Payments to increase community long term care (SMD 9-03-11) Smoking Cessation Guidelines (SMD 6-24-11)

13. New Prevention and Wellness 2010 2011 2014

14. Define MH/SUD Service Coverage: Good & Modern Behavioral Health Benefit Within this world of coverage expansions Need clear, consistent and useful definitions for purchasers of what are good and modern MH and SUD services: Benchmark plans for Medicaid expansion (2014) Essential benefits for state exchanges (2014) Scope of services for Mental Health Parity and Addictions Equity Act Use block grant dollars in new world

15. Evidenced Based “Best and Modern” Benefit Continuum of Services • Recovery Supports (peer support and coaching, self directed care) • Prevention and Wellness Services (screening, health promotion) • Community Supports (case management, supported housing, supported employment) • Other Living Supports (Habilitation) • Engagement Services (assessment, outreach) • Medication Services (includes Medication Assisted Treatment) • Outpatient Services (multi-family therapy, other evidenced based therapies) • Intensive Support Services (ambulatory detox, intensive outpt) • Out of Home Residential Services (adults and youth) • Acute Intensive Services (Urgent and medically monitored)

16. Block Grants 2011—Proposed Changes to BG Application and regulations • Needs assessment for uninsured & Planning for FY 2014 Implementation • Joint Planning Efforts between MH and SA: about ½ submitted this year • Focus on Participant Directed Care • Increased Focus on Recovery Services—bring to scale demo efforts • States Enhancing/Beginning Service Management Efforts • Use of technology for service delivery • Greater Accountability— • More specific information on what is purchased through BG dollars • Performance strategies that mirror National Quality Strategies • 2014 and beyond • Services that are not covered by Medicaid/Medicare/insurance • Individuals that are not covered by 3rd party insurance • Enrollment challenges for those with MI and SUD

17. Major Drivers in the ACA More people will have insurance coverage Medicaid will play a bigger role in MH/SUD than ever before Emphasis on primary care and coordination with specialty care Encourages home and community based services and less reliance on institutional care Preventing diseases and promoting wellness is a huge theme Outcomes: improving the experience of care, improving the health of the population and reducing costs

18. SAMHSA Health Care Reform Road Map for MH/SA State Authorities Organize an implementation team and become ACA experts Understand the new health insurance exchanges Develop a coverage crosswalk and attempt to close remaining gaps Translate eligibility into consumer-friendly enrollment processes Ensure MH/SUD service and workforce capacity Focus on prevention and integration of care to account for all patient needs Ensure quality and efficiency

19. State In Drivers Seat: Think Long Term What are the service needs of people in your State/jurisdiction? What are the outcomes that are important to your system? How do you measure them? What would you need to meet those needs? How much do you need for a good system? How much do you need for the ideal system? What efforts support providers, individuals and families to understand the changing environment How to assure coordination and collaboration of state agencies in their efforts?

20. A benefit package, within available funding, that supports recovery and resilience. Promoting program standards, including common service definitions, system performance expectations, and consumer/family outcomes. Creation of an adequate number and distribution of appropriately credentialed and competent primary care and behavioral health care providers. Funding strategies that will be sufficiently flexible to promote a more efficient system of services and supports. The Systems Vision

21. Wellstone/Domenici Mental Health and Addiction Equity Act of 2008 • Requires that IF have MH/SUD, then: • No greater financial burden (cost sharing, deductibles) than med/surg—Not annual or lifetime limits • Benefits not more limited than med/surg (number visits, frequency of treatment, etc) – Non-quantitative treatment limits • Out of network if med/surg out of network • Transparency in medical necessity & denials of care • Exemptions from law • Employer with less than 50 employees • If costs go up (>2% first year, >1% after that)

22. With More Questions? Trusted sources of information about Reform www.Healthcare.gov www.SAMHSA.gov/healthreform www.kff.org/healthreform http://nashp.org/health-reform www.familiesusa.org/health-refrom-central 22